Quick Overview
Policy Updates
- Maternity Communication Update for All Lines of Business
Policy Bulletin
September 2026 Policy Updates
New Policies
Category
Policy Title (Number)
Date
Summary of Change
Coding/Reimbursement
8/19/2026
Created and published this new coding/reimbursement policy.
Revised Policies
*Changes apply ONLY to Commercial plan policy UNLESS summary text appears in bold.
Category
Policy Title (Number)
Date
Summary of Change
Coding/Reimbursement
8/4/2026
Included billing guidelines for both services that are performed prior to 1/1/27 and for services that are performed after 1/1/27.
Ear, Nose, and Throat
8/13/2026
For Commercial Plan Policy, for section titled, “Utah Based Plans,” changed minimum age requirement for unilateral and bilateral cochlear implantation from 9 months to 7 months.
General Surgery
7/23/2026
For Commercial Plan Policy, added the following note for clarification: “Select Health will cover conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in cases of medically refractory GERD and/or dysphagia attributable to the sleeve gastrectomy, with or without associated hiatal hernia, after failure of maximal medical therapy. Please refer to Select Health medical policy #659 for criteria.”
General Surgery
7/23/2026
For Commercial Plan Policy, added new section B with coverage criteria for Bile Acid Reflux.
General Surgery
7/29/2026
For Commercial Plan Policy, added the following coverage criteria: “Select Health covers mastopexy for nipple-sparing prophylactic mastectomy, if the prophylactic mastectomy meets medical criteria.”
Genetic Testing
8/20/2026
For Commercial Plan Policy, modified requirements in criteria section #16-I, and added new criteria section #16-II with requirements for coverage of the Decipher Prostate RP test; modified language regarding exclusions outlined in section #1 [Barret’s Esophagus], and changed requirement listed in criterion #16-IC to: “The member does not have very low risk prostate cancer, …”
Genetic Testing
8/20/2026
For Commercial Plan Policy, removed previous criterion #3-G: “An affected or unaffected individual, who otherwise does not meet the criteria above, but has a probability > 5% of a BRCA1/2 pathogenic variant based on prior probability models (e.g., Tyrer-Cuzick, BRCAPro, CanRisk); must be performed by the ordering physician.”
Hematology/Oncology
7/24/2026
For Commercial Plan Policy, modified coverage criteria as follows: "Select Health covers allogenic non-myeloablative bone marrow transplants (“mini-transplants”) when either A or B are met: A. The procedure has been recommended and will be performed by an Optum Center of Excellence; or B. The procedure meets InterQual subset guidelines: Nonmyeloablative Allogenic Stem Cell Transplant; and prior authorization is submitted.”
Orthopedic
8/1/2026
For Commercial Plan Policy, modified requirements in criterion #9: “Failure of conservative therapy, as defined by the following: --Physical therapy: minimum of 12 visits within a 6-month period; must have been performed within the previous year (it is recommended that at least four of these visits be performed in person). After 6 visits, additional therapy is not required if contraindicated or is not recommended by the physical therapist. --Documentation submitted by a physical therapist needs to include the evaluation, treatment plan, expectations for improved outcomes, and duration of therapy to meet this requirement; and …” Added clarifying information as footnotes regarding focal articular cartilage defects and the Outerbridge Classification Scale.
Orthopedic
8/20/2026
For Commercial Plan Policy, incorporated coverage criteria for consideration of coverage for anterolateral ligament (ALL) reconstruction procedures.
Physical Medicine
8/1/2026
For Commercial Plan Policy, added the following requirement to criterion #A-1c, #B-1c, and #C1-c: “Documentation submitted by a physical or chiropractic therapist needs to include the evaluation, treatment plan, expectations for improved outcomes, and duration of therapy to meet this requirement; …”; and added the following exclusion: “Select Health does not cover peripheral nerve stimulation for peripheral neuropathies as this is considered experimental/investigational.”
Physical Medicine
8/1/2026
For Commercial Plan Policy, added the following requirement to criterion #1-c: “Documentation submitted by a physical therapist needs to include the evaluation, treatment plan, expectations for improved outcomes, and duration of therapy to meet this requirement …”; and removed the following exclusion that was previously listed in the policy: “The procedure may not be repeated for five years after the initial procedure.”
Physical Medicine
8/21/2026
For Commercial Plan Policy, removed “facet cyst rupture/aspiration” from requirements outlined in in section I (1−4).
Women's Health
7/29/2026
For Commercial Plan Policy, added the following coverage criteria: “Select Health covers mastopexy for nipple-sparing prophylactic mastectomy, if the prophylactic mastectomy meets medical criteria.”
Additional Announcements
- The policies listed below have been modified accordingly, with "Optum Center of Excellence" replacing prior versions with "Intermountain Transplant" or "Intermountain Interventional Radiology" (Effective July 27, 2026).
"Select Health covers [transplant/procedure] when either A or B are met: A. The procedure has been recommended and will be performed by an Optum Center of Excellence; or B. The procedure meets InterQual [specific guideline]; and prior authorization is submitted."- Policy #105: Human Stem Cell Transplantation (HSCT), Bone Marrow Transplantation (BMT)
- Policy #125: Heart Transplant: Adult
- Policy #142: Liver Transplant (Cadaveric)
- Policy #146: Lung (Single or Double) Transplant
- Policy #349: Transcatheter Arterial Chemoembolization (TACE)
- The policies listed below have had the following requirement added to existing requirements for attempts at physical (or chiropractic) therapy: "Documentation submitted by a physical (or chiropractic) therapist needs to include the evaluation, treatment plan, expectations for improved outcomes, and duration of therapy to meet this requirement." (Effective August 1, 2026)
- Policy #622: Cervical, Lumbar, and Thoracic Spinal Fusion with or without Spinal Decompression
- Policy #557: Radiofrequency Ablation of the Genicular Nerve
- Policy #389: Radiofrequency Ablation (RFA) of the Sacroiliac (SI) Joint
- Policy #609: Infusion Pumps
- Policy #595: Sacroiliac Joint Fusions
- Policy #626: Diagnostic and Therapeutic Interventions for Spinal Pain
- Policy #620: Hysterectomy/Oophorectomy (Effective October 1, 2026)
“For all elective procedures listed below, the following requirements apply:- Any patient with diabetes needs an A1c documented within the past 3 months when scheduling an elective hysterectomy/oophorectomy/salpingectomy; A1c must be less than 8%.
- Any patient without diabetes, who is undergoing an elective hysterectomy/oophorectomy/salpingectomy, needs an A1c documented within the past 12 months; A1c must be less than 8%.”
- Policy #514: WGS/WES (Effective October 1, 2026)
For Commercial Plan Policy, requirements in criterion #I-B2 will be modified accordingly: “Neurodevelopmental disorders, including intellectual disability, global developmental delay, or autism spectrum disorder when co-occurring with developmental delays, seizures, or birth defects; …”
- Policy #222: Genetic Testing: Inheritable Colorectal Cancer (Effective October 1, 2026)
The following exclusion will be included: “Select Health considers familial or inherited genetic testing for esophageal adenocarcinoma to be experimental/investigational due to this testing lacking evidence for clinical utility.”
- Policy #357: Genetic Testing for Monitoring Rejection in Cardiac Transplant Patients (Effective October 1, 2026)
The following exclusion will be included to coincide with changing CPT 0087U to not covered/ investigational: “Select Health does not cover the Kashi Heart Molecular Microscope Diagnostic System (MMDx-Heart) for evaluation of cardiac transplant rejection as the safety and efficacy of this test has not been established; this meets the plan’s definition of experimental/investigational."
- Policy #671: Genetic Testing for Monitoring of Rejection in Kidney Transplantation (Effective October 1, 2026)
The following exclusion will be included to coincide with changing CPT 0088U to not covered/investigational: “Select Health does not cover the Kashi Kidney Microscope Diagnostic System (MMDx-Kidney) for evaluation of renal transplant rejection as the safety and efficacy of this test has not been established; this meets the plan’s definition of experimental/investigational."
- Select Health will publish new medical policy #702 (RhinAer) with criteria for coverage of the RhinAer device and CPT 31242. (Effective October 1, 2026)
Coding Updates
Maternity Communication Update for All Lines of Business
Effective January 1, 2027, all current antepartum care CPT codes will be retired and reported per encounter with an Evaluation and Management (E/M) code.
Select Health will continue to require the use of current antepartum care-only codes through December 31, 2026. For pregnancies that span both calendar years, providers should bill services according to the coding rules that are in effect on the date each service is provided.
SERVICES PROVIDED BEFORE JANUARY 1, 2027
Report services provided before January 1, 2027, using the codes and coding rules in effect on the date of service.
Antepartum Care CPT Codes:
- 59425 (4-6 visits)
- 59426 (7 or more visits)
**If only 1-3 antepartum visits are provided before January 1, 2027, bill the appropriate E/M code for each visit.
SERVICES PROVIDED ON OR AFTER JANUARY 1, 2027
The visit during which pregnancy is confirmed represents the official initiation of antepartum care. This visit, as well as all subsequent antepartum services, should be reported using the appropriate Evaluation and Management (E/M) code with the TH modifier appended.
For additional information, please refer to Policy #CR-16: Obstetrical Services.